Formulir Pendaftaran Anggota HPCI
HondaPCX Club Indonesia
Email address *
DATA PRIBADI
PERSONAL PARTICULARS
Nama Lengkap *
Full Name
Jenis Kelamin *
Tempat Lahir *
Place of birth
Tanggal Lahir *
MM
/
DD
/
YYYY
Alamat *
Address
Telepon Selular *
Mobil Phone
Telepon Darurat
Emergency Number
Email *
Email Address
Jenis Identitas *
Type of Identity
Nomor Identitas *
Identity No
Agama *
Religion
Golongan Darah *
Blood type
DATA KENDARAAN
VIHICLES INFORMATION
Nomor Polisi *
License Plate
Warna Motor *
Color Of PCX
Nomor STNK *
No. Reg STNK
Tahun Pembuatan *
Year Manufacture
No. Rangka *
Chassis Number
No. Mesin *
Marchine Number
Catatan
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Pernyataan *
Required
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